The Claims Technical Review Specialist, Sr provides advanced quality review of claims processing and delivers practical training to improve team effectiveness and efficiency in accordance with Company guidelines, client needs, and regulatory requirements.
"Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job Description/Role."
Key Duties and Responsibilities- Reviews the work of new hires and existing employees; audits claims processing to identify areas for individual performance improvement; provides instructional feedback to increase team members’ skill level in claims processing.
- Performs technical review and analysis of all types of claims, including large dollar and technically complex claims, to ensure accuracy and adherence to prescribed procedures and plan guidelines.
- Identifies potential procedural or system issues and suggests possible solutions for process and quality improvements to management.
- Delivers practical training to new and existing employees on systems, plans, policies, and procedures. Updates training aids as needed.
- Tests new plan benefits or changes loaded into the claims system to ensure accuracy, adherence to plan guidelines, and system integrity.
- Completes and submits internal tickets to resolve claims adjustment errors or request claims system enhancements.
- Assists in the maintenance and upkeep of job aids and SOP’s.
- Performs other duties as assigned.
- High school diploma or GED.
- Five years of experience processing all types of group health benefit claims.
- Experience working in a third-party administrator or Taft-Hartley environment.
- In-depth knowledge of all aspects of benefits claims processing and claims adjudication principles and procedures.
- Excellent working knowledge of terminology related to processing medical and dental claims such as HCFA, CPT-4, ICD-10, HCPCS.
- Experience interpreting Plan documents and/or certificates of coverage related to benefits, eligibility, exclusions, and limitations.
- Ability to calculate figures and amounts such as discounts, interest, proportions, and percentages.
- Excellent attention to detail, problem solving skills, follow-through, and strong verbal and written communication skills.
- Proven ability to work independently and deliver results.
- Strong working knowledge of Claims systems.
- Excellent written and oral communication skills.
- Computer proficiency including Microsoft Office tools and applications.
Preferred Qualifications
Experience as a practical trainer.
*Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee of this job. Duties, responsibilities and activities may change at any time with or without notice.
Working Conditions/Physical Effort- Prolonged periods of sitting at a desk and working on a computer.
- Must be able to lift up to 15 pounds at times.
Consistent with the Americans with Disabilities Act (ADA) and other applicable federal and state law, it is the policy of Zenith American Solutions to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Recruiting Department at [email protected], and we would be happy to assist you.
Please note that in compliance with certain state law, we are displaying salary. This rate is intended for hires into this location.
Compensation: $30.28/hr
Zenith American Solutions
Real People. Real Solutions. National Reach. Local Expertise.
We are currently looking for a dedicated, energetic employee with the necessary skills, initiative, and personality, along with the desire to get the most out of their working life, to help us be our best every day.
Zenith American Solutions is the largest independent Third Party Administrator in the United States and currently operates over 44 offices nationwide. The original entity of Zenith American has been in business since 1944. Our company was formed as the result of a merger between Zenith Administrators and American Benefit Plan Administrators in 2011. By combining resources, best practices and scale, the new organization is even stronger and better than before.
We believe the best way to realize our better systems for better service philosophy is to hire the best employees. We're always looking for talented individuals who share our dedication to high-quality work, exceptional service and mutual respect. If you're interested in working in an environment where people - employees and clients - really matter, consider bringing your talents to Zenith American!
We realize the importance a comprehensive benefits program to our employees and their families. As part of our total compensation package, we offer an array of benefits including health, vision, and dental coverage, a retirement savings 401(k) plan with company match, paid time off (PTO), great opportunities for growth, and much, much more!
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What We Do
Zenith American Solutions’ mission is to compassionately care for America’s Workforce so that they can live more secure, productive, and healthy lives. As the largest independent Third Party Administrator in the United States, we have the depth and breadth of people, services and technology to provide custom plan solutions and local personal service for our clients and their members.
